Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00274583 Renewal 09/23/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.65The bathroom window did not open and there was no other source of mechanical ventilation.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. On 9/23/2025 after the licensing inspection the bathroom window lock was release and the window opened. Also in August 2025 an outside contractor ensured all windows were able to be opened in all M-5 houses, see attachment number 2. On September 2, 2025 at the house meeting the bathroom window was opened as well as all of the windows. Attachment number 3 shows the bathroom window open. 09/23/2025 Implemented
6400.111(f)The attic fire extinguisher has not been inspected since 03/2024. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. The inspected and approved fire extinguisher was placed in the attic on 9/23/2025, attachment #5 picture of fire extinguisher in attic. The executive director will go with the fire safety expert to each house making sure all fire extinguishers are inspected and approved annually, although this was done at the annual inspection on 3/21/2025 #14 which notes the attic had a proper fire extinguisher. 09/23/2025 Implemented
SIN-00253197 Renewal 09/25/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.65The windows in two of the individuals' bedrooms were unable to be opened and stuck shut.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. The windows will be opened within a day of the trim being painted to ensure the windows are not stuck. The monthly house check form will now include checking to make sure the windows open. We are a small agency therefore the Program specialist will check this when checking the house monthly. On 9/28/2024 and 9/30/24 the maintenance person opened all windows that were closed. pictures attachment #1 and attachment #2 show the opened windows.at the site noted. The windows at all houses are being checked each month. 10/01/2024 Implemented
SIN-00231979 Renewal 09/27/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(a)The smoke detector is inoperable in the attic. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. During the day of the inspection a smoke detector was placed in the attic. The Fire system company was contacted, according to them they were receiving a signal from the alarm which meant it would activate the other detectors. The fire protection company came out October 24, 2024 the system tested okay, all communications tested okay and fire system is now normal. Attachment 2 09/27/2023 Implemented
SIN-00213225 Renewal 09/28/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(e)(14)The assessment does not reference individual 2's current ability to swim or safety around bodies of water; it only mentions his ability to swim in childhoodThe assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. I struggled with this because just because you haven't been swimming in years doesn't mean you cannot swim, however I will put what is expected from licensing. Individual 2 has not been swimming since he was a child based on family information and himself. He does not wish to go swimming or to a beach, I could say he does not have the ability to swim, since it has not happened since his childhood 11/01/2022 Implemented
6400.217A current, signed copy of individual 2's consent for info release was not found in the record.Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it. The record for individual 2 did have the release of information, unfortunately it was missed during the upload as we were experiencing technical problems. 10/03/2022 Implemented
6400.196(a)Staff 2, direct support staff, did not have training on behavior plan for individual 2A staff person who implements or manages a behavior support component of an individual plan shall be trained in the use of the specific techniques or procedures that are used.New hire staff 2 did have training to individual 2 behavior support plan as noted on Pre service training 4/7/2022 it's included with the program planning and ISP. A revised preservice training form was created to specifically include behavior support. document #7 10/10/2022 Implemented
SIN-00193626 Renewal 09/28/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(b)Some poisons were stored unlocked in this residence. Individual #1's ISP indicates he is aware of poisons, but they are to be locked due to the need for supervision during use.Poisonous materials may be kept unlocked if all individuals living in the home are able to safely use or avoid poisonous materials. Documentation of each individual's ability to safely use or avoid poisonous materials shall be in each individual's assessment.Individual #1 Supports Coordinator was contacted to correct his ISP to poisons do not need to be locked. This will match the annual assessment that notes poisons do not need to be locked. See attachment #14 10/04/2021 Implemented
SIN-00149522 Renewal 01/31/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.167(b)On 1/14/19 Individual #1's glucometer reading indicated 156, 110 and 201 for blood sugar levels. However, on the MAR 110 was documented. Per sliding scale individual was supposed to have 2 units of insulin -- There was no documentation of insulin administration. Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant.The procedure for recording the glucometer reading was reviewed with all staff by the nurse on 2/5/19 and 2/16/19. The procedure included not allowing the individual to give the glucometer reading to the staff. The review by the nurse of the glucometer reading the first 2 weeks in February 2019 matched the recording in the MAR. The glucometer comparison with the MAR will be checked weekly by either the trainer or the nurse. 02/16/2019 Implemented
6400.194(b)Individual#1's review committee form did not include a majority of outside members. Signatures on the review committee signature sheet only included members from the provider's agency only.The restrictive procedure review committee shall include a majority of persons who do not provide direct services to the individual.On 2/1/19 the CEO contacted 3 outside members (doctor office receptionist, retired teacher, and a retired person) who agreed to serve on the peer review committee. On 2/8/19 these outside members and 1 staff from M-5 reviewed the restrictive procedure of individual#1. This peer review committee will review any other restrictive plans. The CEO will make sure the committee continues to consist of a majority of outside members. 02/08/2019 Implemented
SIN-00106082 Renewal 12/01/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(10)Individual #1¿s annual physical dated 9/22/16 did not indicate whether or not they were free from communicable disease.The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. The physical dated 9/22/16 was corrected to address the free from communicable disease and the specific precautions to be taken to prevent spread of the disease to others. Physicals will be reviewed prior to filing to insure non of the sections were omitted,when there is an omission the physical will be returned to the physician to complete. 12/06/2016 Implemented
6400.141(c)(15)Individual #1¿s annual physical dated 9/22/16 did not indicate recommended diet or special diet instructions.The physical examination shall include:Special instructions for the individual's diet. Dietary needs were added to this individuals physical. The sections on the physical will be reviewed prior to filing to ensure nothing has been omitted or mistaken to avoid a non compliance. 12/15/2016 Implemented
6400.161(e)Individual #1¿s medication Eucerin was discontinued but the medication was still in the Individual¿s medication box. Discontinued prescription medications shall be disposed of in a safe manner.Eucerin is a non prescription over the counter lotion that was in the medication box as a reminder to staff to apply lotion to this individual. To not confuse the licensing representative although this was the best reminder for staff, this lotion or any other non prescription lotion in the future will not be in the medication box. 12/06/2016 Implemented
6400.181(c) Individual #1¿s annual assessment dated 7/23/16 does not indicate what instruments the assessment were based on. The assessment shall be based on assessment instruments, interviews, progress notes and observations. The form indicating that interviews, progress notes and observations were the instruments the assessment was based on, was placed with the assessment. The document listing the instruments of what the assessment was based on will be stapled to the assessment to avoid a non compliance. 12/06/2016 Implemented
6400.181(e)(13)(iii)Individual #1¿s annual assessment dated 7/23/16 does not indicate progress and growth in the area of Activities for Residential Living. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. Progress and growth was added in the area of activities for residential living. To avoid this non compliance in the future the Progress and growth heading was added to the activities for residential living area. 12/06/2016 Implemented
SIN-00176914 Renewal 09/24/2020 Compliant - Finalized
SIN-00124618 Renewal 10/24/2017 Compliant - Finalized
SIN-00048161 Renewal 03/26/2013 Compliant - Finalized